New Study Looks at Appropriate Use of Chiropractic

"The message of our new study is a mixed one. First, everybody needs
to stop treating chiropractors as if they are quacks." -- Paul Shekelle,
MD, PhD

if (isset($google_rectangle_slot)){
?>
}else{
?>
}
?>

The July issue of the Annals of Internal Medicine features "The
Congruence between Decisions to Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America." The
authors of the paper are well-known to chiropractic: Paul Shekelle, MD,
PhD; Ian Coulter, PhD; Eric Hurwitz, DC, PhD; Barbara Genovese, MA; Alan
Adams, DC; Silvano Mior, DC; and Robert Brook, MD, ScD.

The reason for the study is presented in the abstract:

‘ manipulation for some patients with low back pain. If followed, these
guidelines are likely to increase the number of persons referred for chiropractic
care. Concerns have been raised about the appropriate use of chiropractic
care, but systematic data are lacking."

The authors used a retrospective review of chiropractic office records
to "determine the appropriateness of chiropractors' decisions to use "spinal
manipulation" for patients with low back pain." They compared a "preset
criteria for appropriateness" to the actual chiropractic patient records.
The appropriateness criteria used was that established in the RAND study1
for low back pain using a multidisciplinary panel.

From each office they randomly selected 10 records of patients presenting
with low back pain. Of the total number of 1,310 patients, 1,088 (83%)
received some form of spinal manipulation. Of these, 859 (79%) had patient
records containing sufficient information to determine whether care was
congruent with the RAND appropriateness criteria.

The following table was presented as a breakdown of their findings:

Table 3.‘

According to Type of Treatment Receivedå(#`

å

«
ClassificationÆ™™ Æ Æ Æ
AppropriateÆ™™

UncertainÆ`

`

Inappropriate

As the table shows, chiropractic care received by the low-back pain patients
was considered appropriate 46 percent of the time. The conclusion of the
authors was:

"be congruent with appropriateness criteria is similar to proportions
previously described for medical procedures; thus, the findings provide
some reassurance about the appropriate application of chiropractic care."

On the negative side, the chiropractic care delivered was considered
inappropriate in 29 percent of the cases and uncertain in 25 percent.
The authors note "parallels" between these results and those for conventional
medical procedures:

"rates of appropriate and inappropriate use for carotid endarterectomy
were 35% and 32% and the rates for coronary artery bypass graft surgery
were 56% and 14%.

The authors provided examples of patient presentations that would
be considered appropriate, inappropriate and uncertain. Broadly speaking,
patients with "acute low back pain with no neurologic findings and no
sciatic nerve irritation" were considered appropriate for spinal manipulation.
Those judged inappropriate or uncertain were "generally mixtures of
subacute and chronic back pain syndromes, some of which were not assessed
with lumbosacral radiography."

In their discussion, the authors directed their attention to medical
referrals:

"with low back pain may be independently and concurrently seeing
chiropractors, and not all of this care is uniformly appropriate or
inappropriate. Patients with indications that are inappropriate for
spinal manipulation should be advised of this. Similarly, for patients
with appropriate indications, internists should offer spinal manipulation
as therapeutic option of accepted efficacy; in many settings, referral
to a chiropractor is the most practical way of achieving this. Others
have published suggested criteria for primary care physicians to use
in identifying chiropractors who would be suitable for such referrals.
An additional clinical implication of our study is that the use of so-called
rigorous as those used to evaluate medical practices."

In a corresponding news release issues by the RAND Corporation, primary
investigator Dr. Paul Shekelle made these comments:

"needs to stop treating chiropractors as if they are quacks.
An appropriateness rate of roughly half is in the same ballpark as the
findings for certain medical procedures when appropriateness measures
were introduced a dozen years ago. Chiropractors are appropriately treating
some patients, and those patients are likely to benefit as a result
of their care.

"the missions of a health profession is to pursue and incorporate
research on quality. Clearly, a 29 percent inappropriateness rate is
too high and should be decreased."